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The Maynard Doctrine: What efficiency is

Health economist Professor Alan Maynard teaches Health Secretary Jeremy Hunt a little about efficiency.

What is efficiency?

On September 11th, I tweeted: "Health care that is delivered inefficiently is unethical as it deprives potential patients of care from which they could benefit".

On September 15th, a young chap called Jeremy Hunt tweeted in reply "This is why safe, high quality and efficient care must go hand in hand”.

The problem with this reply is that it is confusing and confused: i.e. an inefficient way to communicate and formulate policy. Efficiency, safety and quality are not separate entities.

Efficiency encapsulates the latter two activities. Focusing on quality and safety as separate goals diverts attention from the pursuit of overall efficiency in the use of NHS resources.

In our world of scarce resources. all health care choices involve valuation of what is given up when care is delivered (cost), and what is gained for patients in terms of enhancements in the length and quality of their lives (benefit).

In all public and private health care systems, budgets are limited. The assumption in the NHS is that choices between patients competing for care are based on evidence of cost and patient benefit.

Use of this efficiency criterion ensures that from the limited NHS budget, the maximum amount of benefits are provided for patients.

This simple proposition is confused by discussion of “safety” and “quality” as separate entities. How much safety investment, at what cost?

We all desire a safe environment in which to receive our care. However, this is merely one facet of efficiency. Safety must be studied by valuing its cost to the NHS and society - and its benefit to patients.

Sadly, safety fanatics advocate safety policy - often implicitly arguing that the level of risk should be zero.

This is bunkum. Every safety initiative involves giving up resources that could be used to deliver health care to patients.

Safety has an opportunity cost. Investments in it need to be carefully evaluated.

Safety investment cannot reduce all patient risks to zero There is an efficient level of funding it, which needs to be identified - rather than merely asserted by the apostles of false hope. Caveat emptor: buyer beware!

The investigation into the Mid Staffordshire hospital (the Francis report) was a classic example of a well-intentioned lawyer listing dozens of largely evidence-free proposals with practically no regard to evidence of benefit or opportunity cost. It was an unethical way to pursue the efficient production of patient safety.

The Francis report also led to the Care Quality Commission, which cost over £250 million, as reported in its last annual report. Where is the evidence that this large investment was efficient and actually improved patient welfare?

Without such evidence, that investment may be inefficient and unethical.

The US-based Institute for Health Improvement (IHI) was a reaction to a critical report entitled “To Err Is Human” from the Institute of Medicine. It identified medical errors as a major cause of avoidable morbidity and mortality. Subsequent investment in the USA by the IHI and others has created significant opportunity costs, but with largely inadequate quantification of value for money and patients.

The need for scientific rigour is acute and universal when resources are limited.

Until evidence is provided, such investments are unethical as they deprive patients of care from which they could benefit. Religious zealotry in spending society’s scarce resources is not a good basis for investing in the unproven.

How much quality, at what cost?
Let us agree that we all want to maximise the length and quality of our lives.

Let us also agree that the issue of opportunity cost cannot be avoided.

When, for instance, ingenious scientists at Roche Pharmaceuticals identify a new chemical entity for the treatment of my cancer, I want it! But if its price is £90,000 per Quality-Adjusted Life Year (QALY), the National Institute of Health and Care Excellence will probably say no. This is even more likely if the product only gives me, the patient, a few quality-adjusted life months (QuALMS)!

Once again, the issue is this: quality has to be valued in terms of what is given up and what is gained for patients, as ipart of the measurement of efficiency.

Investing in quality regardless of cost may be consistent with individual patient demand, but ignores the needs of other patients who can benefit more.

The problem is efficiency
The blurring of the issues of safety and quality as entities separate from efficiency is unethical. It can lead to the misallocation of resources. The term 'efficiency' encapsulates safety and quality in the measure of patent benefit and opportunity cost.

The problem for Mr Hunt is that the public (if hopefully not him) likes 'comfort 'words such as “safety” and “quality”, and do not understand the comprehensiveness of the word “efficiency”.

Mr Hunt, poor dear, has to deal with dunderheads at the BBC and the Daily Mail when they pontificate and pressurise him - unethically and inefficiently!

Hopefully in time, he can educate society better and ensure that all health care investments identify the value of what is given up (e.g. the costs of treatment therapies as well as inherent investments in safety and quality) and what is gained by these composite activities.

In the meantime Mr Hunt, please stop confusing your terms - and why not express doubt about fanatical advocates of dubious investments? They are always at your door, and sometimes sadly listened to by uncritically you and yours in error!

Good luck: you will need it.